PARACETAMOL FOR PAIN IN ADULTSSaragiotto BT, Abdel Shaheed C, Maher CG. Paracetamol for pain in adults. BMJ 2019;367: l6693.

Objective & Methodology:

Publication objective is to provide an overview of efficacy and safety of paracetamol as analgesic in adults in primary care settings.

Systematic reviews (comparing paracetamol versus placebo in adults) searched from Cochrane Library, MEDLINE and EMBASE until January 2019, and recent clinical guidelines.

Discussion:

Paracetamol effectiveness Currently, paracetamol is the mainstay analgesic with a long history of use and has been studied extensively for the relief of mild to moderate pain. Several evidences have shown the efficacy of paracetamol in multiple pain indications.

The high-quality evidence has demonstrated paracetamol (single dose of 1000 mg) as an effective treatment in tension-type headache within two hours of administration. A systematic review comprising 6 RCTs and 2162 participants, has found paracetamol to be similar efficacious to other NSAIDs in the treatment of headache. Paracetamol (1000 mg, single dose) was further shown to be effective in treating acute migraine headache, however, the quality of evidence was low with a smaller effect size than other commonly used analgesics. Paracetamol is also used in post-surgical dental pain, though evidence suggests its inferior efficacy to ibuprofen for such condition.

Studies have shown the uncertain benefits of paracetamol in musculoskeletal pain conditions. High-quality evidence from Cochrane review showed that immediate and short term (up to 12 weeks) treatment of paracetamol does not provide clinically important improvement in musculoskeletal conditions like knee or hip osteoarthritis. However, the comparative evaluation of paracetamol to other NSAIDs have shown mixed results in such conditions. A recent network meta-analysis showed paracetamol to be inferior to celecoxib and the glucosamine and chondroitin combination for the treatment of knee or hip OA. However, yet another review showed similar efficacy to NSAIDs for OA treatment.

A case presented in this article is about a 65-year old overweight and physically inactive male suffering from OA knee pain. The GP advised the use of paracetamol and consider adding topical NSAID/ heat pack for better control of his flared-up pain along with explaining the role of physical exercise in the long-term management of OA

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For Healthcare professionals use only.

Osteoarthritis (knee or hip)

Mixed evidence regarding comparative effectiveness of paracetamol in immediate and short term (

For Healthcare professionals use only.

Can be used in all pain conditions

General Pain Acute back

pain Dysmenorrhea

Postoperative

pain Childhood

.. -

1

I

I

I

I

Migraine Osteoarthritis Dental pain

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Consider using combinations of acetaminophen

and/or oral NSAIDs

with caffeine

Consider using topical NSAIDs

before oral NSAIDs, or in

combination if pain is severe

' I

I

Consider using a combination of oral NSAID

and acetaminophen

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I I

Also consider topical NSAIDs

plus acetaminophen if pain relief is

inadequate

Also consider using a combination of glucosamine and

chondroitin

.. -

1

I

I

I

I

Pregnancy

Older people

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Use oral NSAIDs with caution

(pregnant women:

caution in first trimester,

discontinue use by week 32)

Figure 1. Nonprescription acetaminophen and oral nonsteroidal anti-inflammatory drugs can be used initially in all

types of acute pain and in vulnerable groups such as children, pregnant women and older people. Where oral NSAIDs

are contraindicated or not tolerated, acetaminophen is the treatment of choice, or topical NSAIDs in osteoarthritis. It

should be noted that nonpharmacological options (which vary according to the pain indication, but include measures

such as physical therapy, lifestyle changes, etc.) are usually recommended alongside pharmacological therapy, for

optimal pain relief. NSAID: Nonsteroidal anti-inflammatory drug; TTH: Tension-type headache.

• Conclusion

• Overwhelmingly, acetaminophen and oral NSAIDs represent the first line of management across all painconditions in adults, particularly for mild-to-moderate pain & for some sever pain cases, such asosteoarthritis & postoperative pain.

• Oral NSAIDs should be used cautiously in pregnant and older population.

• Acetaminophen (Paracetamol) is recommended as the treatment of choice where oral NSAIDs arecontraindicated or not tolerated.

• Topical NSAIDs are preferred over oral NSAIDs for indications like osteoarthritis.Though this summary can be a useful tool, specific guidelines mustalso be referred.

Panadol is approved for a range of pain types*

� Musculoskeletal

pain

i'!'Itl Toothache

� Headache

� Muscle ache

� Period pain

i'!'Itl Joint pain

� Mid-to-moderate

pain associated

with cold and flu

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Item Code:PM-SA-PAN-20-00011Preparation Date: June 2020

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